National Defence Committee on Dec. 11th, 2020

[Col Rakesh Jetly]

That's an excellent question, because the answer is that in 30 years of working in mental health, specifically in the last 20 years, and sadly being involved with virtually every suicide investigation we've had in the CAF, certainly in the last 10 years, I've never truly seen this specifically stated by a patient or by their family as a reason for the person's not coming. But, again, you can never disprove a negative; that's a scientific impossibility.

I believe there are barriers to care. I think I mentioned them. Barriers to care include stigma; not being aware of having a mental illness, such as “I'm 40 years old and I'm dragging ass, and maybe it's depression, and maybe not”, and that kind of idea; and certainly concerns about one's career are very valid and come across all our allies.

We never specifically ask them if they're afraid of being punished, but it's a case of, “If I come forward with a mental illness or any kind of health illness, will it impact my employability or universality of service?”

So, I do not have any knowledge at all about paragraph 98 (c) specifically in the Canadian Armed Forces that I have ever heard from a patient or a colleague. I'm the senior person. If it were coming up among our contractors and our uniformed members, I probably would have heard of it; but, again, that does not disprove a negative. Of course, people's concern for their career is a valid barrier to care.

[The Chair, Liberal, Karen McCrimmon]

Thank you very much.

We'll move on to Monsieur Brunelle-Duceppe, s'il vous plaît.

[Alexis Brunelle-Duceppe, Bloc, Lac-Saint-Jean, QC]

Thank you, Madam Chair.

I want to thank all the witnesses for being here today and for their service in the Canadian Armed Forces.

My first question goes to all the witnesses.

In the Canadian Armed Forces Suicide Prevention Action Plan, we read that “a history of attempted suicide is the number one predictor of future attempts”. It also says that self-harm increases the risk factors for suicidal behaviours.

Do the Canadian Armed Forces keep data on attempted suicide or self-harm among the members? If so, do they use those data to establish their policies?

[Col Rakesh Jetly]

I'll start with that.

The whole science of going from intent, to ideation, to attempt—either serious attempt or “not serious attempt”—then to the actual suicide act is a bit.... There's some debate in academia as to how somebody transitions through it. Are there differences between serial attempters versus completers? I think that's the key.

You can never really get a good, reliable number of attempts, and I've attempted to speak about this with your predecessors. If somebody has an overdose on a Friday and wakes up on a Saturday and carries on with their day, we'll never know about it.

We have in place a reporting policy so that if somebody in the chain of command becomes aware of a suicide attempt, a form is filled out. We collect the information, and the communication between leadership and the senior medical authority on the ground is to ensure that the person is in care. The chain of command and the senior medical authority, whom we'll call a “base surgeon” given my army background, will communicate, because sometimes the boss knows or the military police might find somebody, and you have to make sure that the doctor knows. It's just to make sure they're on the same page.

That's sent up to our headquarters within our directorate, and we track it. We do have the numbers, and I believe in a separate filing we produced that document. I don't have it right now, but it's coming to you folks.

Our emphasis is ultimately on getting the person into care. The cognitive behavioural therapy suicide, or CBTS, treatment that we've implemented in the last few years, with training across the country, is in both official languages is in effect a pivot that follows academia. In most of my career, growing up, when somebody was depressed and suicidal, you treated the depression as hard as you could to try to make the depression better. Cognitive behavioural therapy for suicide helps you to target suicidal behaviour specifically, giving a person the safety, skills and safeguards to try to prevent it.

The suicide attempt approach really comes down, in our medical system, to ensuring that the chain of command knows what resources are available for their people, and our clinicians, on a one-to-one basis, help them get the skills to attempt alternative coping rather than self-harm.

[Alexis Brunelle-Duceppe, Bloc, Lac-Saint-Jean, QC]

Wow, that was a very detailed answer. Thank you very much. Let me also take this opportunity to wish you an excellent and happy retirement, Colonel Jetly.

I have another question for you. Major Karoline Martin came to the committee on November 27. She works at the Canadian Forces Health Services Training Centre. In her testimony about Operation Laser, she told us that, when the clinicians began working at long-term care centres, they recognized very quickly that they had a high risk of mental health problems or long term repercussions.

Do you share that fear? Can you tell us a little about the actions that are needed immediately?

[Col Rakesh Jetly]

I absolutely share the concerns. We are asking our soldiers—and service members in general—to do some things. We're going to unfamiliar ground. As somebody who has been around long enough...I was in Rwanda a few years ago and saw a lot of death and a lot of suffering in places like that.

It's a two-pronged approach. The Road to Mental Readiness, education, training, self-care and coping was given to the people before and after the deployment, so they have the tools and know what resources are available. I think you heard about that from Lieutenant-Colonel Bailey, my colleague, who's been in the next office to me for about a decade. It's a great program that many of our allies are borrowing, as well.

On the other hand, in my curiosity hat, a few of us got together very opportunistically and thought that this would be a very important topic to study. We have started what we call a “mixed-methods longitudinal study” to study the impact of a deployment. We are doing surveys, questionnaires and interviews to see the impact.

To be honest with you, as a clinician scientist, I'm very curious. I could see some young soldiers perhaps wondering what the hell they are doing in this kind of deployment because it wasn't what they signed up for. On the other hand, somebody else might think that it's really nice to help people in their own country instead of 7,000 miles away.

We have this curiosity, which is surveying, questionnaires and interviewing to see the mental health impact and to see whether people felt well-prepared about the training, which will feed back to leadership.

We're also looking at the concept of moral injury, which is whether seeing the death, dying, suffering and helplessness leads to guilt, shame and other components.

It's two-pronged. We're absolutely looking after them in the best way we can from a practical point of view, but we're also curious and learning. I think many of us feel that domestic operations like this are going to carry on. We're doing research to continue, as a learning organization, to feed back our findings. This is the other thing we're doing.

[Alexis Brunelle-Duceppe, Bloc, Lac-Saint-Jean, QC]

Thank you very much.

[Col Rakesh Jetly]

My pleasure.

[The Chair, Liberal, Karen McCrimmon]

Thank you very much.

Mr. MacGregor, please.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you so much, Madam Chair, and our witnesses.

I'm here on behalf of my colleague Mr. Randall Garrison today. On his behalf, I want to go along the line of why exactly we still have paragraph 98(c) in the act. Our witnesses clearly identified the fact that only two cases, I believe, were prosecuted in the last 20 years. Is it setting the wrong tone by treating self-harm as a disciplinary matter rather than a mental health concern? I realize mental health issues are very complex and there's a very wide spectrum.

Maybe our witnesses can inform the committee. Has there just been a general reluctance to engage with paragraph 98(c)? Is there anything you can provide that would illuminate us on that?

Thank you.

[RAdm Geneviève Bernatchez]

Thank you. Perhaps I can start answering the question, and then my colleague, Colonel Wry, could provide other information.

On the use of paragraph 98(c) twice since 2000, it's always very difficult in any justice system to explain why a particular section is used or not used. For example, in the military justice system we know that approximately 70% of the charges being laid all pertain to the same type of category. They are there to address circumstances that prevail at the time at which they are used. Perhaps—and this is only speculative—paragraph 98(c) has acted as a dissuasive to those who specifically intended to injure themselves to escape service, dissuading them from doing it because they knew that the offence was on the books. I don't know that; I'm just offering that as a possibility.

The other thing I can point to is that before paragraph 98(c) is used, like most offences, there will be a whole-of-command approach to advising those who would lay the charges and would dispose of the charges. The commanding officer would be consulting with his medical officer in such circumstances. Is the person identified as someone who is not apt to stand trial or is suffering from a mental injury?

They will also receive legal advice from their legal adviser. Is it appropriate or not to charge under this specific section of the National Defence Act? This is something that the charge layer would have to be advised of and there would be consultation. Advice would be provided to the charge layer to ensure that there's not inappropriate use of the charge.

Perhaps my colleague could provide further information.

[Col Jill Wry]

Thank you.

The only thing I would add is that it's important to remember that the purpose of the code of service discipline—and the military justice system, of course—is to advance and support discipline, morale and efficiency in the Canadian Forces. Part of the way it does that is through the processes that it brings forward, both to deter activities and conduct that will take away from the discipline, efficiency and morale, and also to provide a mechanism by which to enforce those offences and enable that conduct.

It's important to see that paragraph 98(c) is part of a larger mosaic of service offences that exist under the military justice system to serve to deter conduct and behaviour that would diminish the efficiency, discipline and morale of the Canadian Forces.

Thank you.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you.

Talking about that “mosaic”, Colonel Jetly, you talked a bit about this in your opening statement. What's the current state of mental health resources in the Canadian Armed Forces? What's the current state of waiting lists? Are there any vacant positions that are still a part of the problem? We do have some statistics about the extra demands that there are and the long wait times.

[Col Rakesh Jetly]

Yes, on the staffing, again, I will commit to providing the numbers on specific staffing. When I last checked, about 90% of all of our positions were filled. That has been a sort of a steady state for the last few years. A lot of it is due to normal attrition. Often we have challenges when a lot of the civilian clinicians who work are spouses of military members who get posted and moved around, which becomes part of the issue.

Mental health professionals are also in high demand. Our ratio of mental health providers to service members is one of the highest in NATO, so we are sort of lucky to be well resourced in those ways.

Wait-lists are something that we're always tracking. We're always looking for more efficiencies. The way we address it is that we have a regular receipt of wait-lists. We have our benchmarks. It's difficult, because there aren't really good civilian benchmarks for wait-lists for mental health, as opposed to knee and hip surgeries and things like that, but if people are outside of our guidelines, we work with the base to identify the reasons and the solutions that we do have, which I'm hoping.... I mean, a silver lining from COVID is the increased comfort with and use of telepsychiatry and telemedicine, because certainly a more distressed base can have access from other bases.

There's a good use of this in the triangle between Esquimalt, Vancouver and Comox, those three, a triangle in B.C. where having psychiatry or psychology reach out to the other bases and avoid travelling.... We're hoping for one like that to sort of even the playing field because, as you know, we have bases in very isolated places and we have bases like Halifax, which is within walking distance from a university centre.

It's an ongoing thing, with ongoing tracking and an ongoing challenge. We're far from crisis mode right now. We're in a steady state. We could always strive to be better, though. I'll give you the specific numbers in terms of HR.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you.

Allow me to say thank you for your service and congratulations on your retirement.

[Col Rakesh Jetly]

I appreciate that. Thank you very much.

[Dr. Kyndra Rotunda]

Could I just talk quickly on that question?

[The Chair, Liberal, Karen McCrimmon]

Yes. Go ahead, Professor.

[Dr. Kyndra Rotunda]

Thank you.

I just wanted to jump in one point, which is that [Technical difficulty—Editor] how many malingering cases there are. It's often not a perfect gauge to say how many reported cases there were. The reason I say this is that when I have Shepardized our section as well, I only get a handful of cases that actually went all the way through the military justice system.

What we see in our clinic is that quite a few of the cases we see—in fact, the majority of them—are people who did not go through a criminal process, but through an administrative process where they were separated with a lower-level discharge, the reasoning being just malingering—an attempted suicide charged as malingering.

Those never come up through the system, so on our side, if you were simply to look at the number of reported cases we have, that's not really representative of the problem we have, because so much of it is happening at a lower level. Our service members then cannot get some of the benefits that they need at the VA. I'm not sure how that works in Canada, so I just offer that for what it's worth as you evaluate the extent of the situation in Canada.

[The Chair, Liberal, Karen McCrimmon]

Thank you very much, Professor.

We go now to Mr. Dowdall.

Go ahead, please.

[Terry Dowdall, Conservative, Simcoe—Grey, ON]

Thank you, Madam Chair.

I too want to thank you witnesses for coming back once again today. Thank you very much for that and for your years of service.

Colonel Jetly, I want to thank and congratulate you. I'm sure you're quite excited to move on to that next stage in life.

In 2016, we did a report of the Mental Health Expert Panel on Suicide Prevention, a joint suicide prevention strategy, which highlighted that for some of our members, the transition period between being released from the Canadian Armed Forces and becoming a veteran could be a particularly stressful and a vulnerable time.

My riding is Simcoe—Grey, which has one of the largest if not the largest base, CFB Borden. What we find here is that many of the individuals decide after their military career to stay in Wasaga Beach or Alliston or Angus, or some of the other local areas here, which is good. We certainly want to find a way for them to seamlessly integrate into our community here. I've heard many times throughout the years that they seem to lack that 24-7 in-person support close by. I know that if someone has stress or mental health issues, for instance, they have numbers and they have to go to Toronto, but driving in Toronto, if you weren't stressed before, you will definitely be stressed by the time you get there.

So my question for you is this. With what we've heard and talked about in this area, do you think it would be a good idea to reach out? I know we're doing a hospital expansion down here in Alliston, which it borders on. Would it be a good idea to work together to put some of those services close so that they're still here in the communities that they're in to hopefully help them through that stressful time? I know they're also stressed as well with the backlog in Veterans Affairs, so I think it's our duty to do anything we can to help them out.

[Col Rakesh Jetly]

It's a very multi-pronged question and it's interesting because I did spend my first four years in Borden, so I know Alliston, Angus, Barrie, the whole area, and I have a lot of pleasant memories of that area.

On transition, I think, we are learning more and more, as are our allies, about transition, and one thing that I've been speaking about a lot with my colleagues is the concept of transitions in the plural sense.

Borden is a training base, and many, many people come in from civilian society and there's that harsh transition into the military. They've just finished basic training. They're away from family and they're learning their skills, their trades. The first year, the first couple of years, we do have suicides, we have self-harm in our officer cadets, in our young soldiers who are starting off. There's the transition coming back from deployment. That first year after deployment is also a time of elevated risk of family difficulties, self-harm and mental illness. So that's why we have the screening, and the reintegration. We've changed the way people come home from deployment.

Then of course, yes, there's the transition out from the forces. It's a stressful time regardless. It's a difficult time regardless. You have to get provincial health cards again. You have to do all kinds of things that you haven't done before, such as find a family doctor, which is also stressful. Then if you add mental illness to that on medical release, you've sort of increased it even further.

In terms of the health care provided in local hospitals, I think it's Stevenson Memorial, if I remember correctly?

[Terry Dowdall, Conservative, Simcoe—Grey, ON]

Stevenson is the one that is actually going through a redevelopment. There have been discussions about perhaps working together. It would be good money well invested, and perhaps we could save some money and at the same time save some lives.

[Col Rakesh Jetly]

Yes, so the idea—and again, this is the difference between Canada and the U.S.—is that our health care, the provision of health care for our forces, by definition, is in partnership with the civilian health system. You know, we do cross that with federal funding, but we do not have hospitals anymore. We don't have 24-7, and when I started, we did. We don't do our own surgeries, so in a sense we are always in a partnership and really, it's the local senior medical authorities who develop those relationships. The base in Fredericton develops the relationship with the local hospital in Fredericton, and those types of things.

What I would encourage there is to have the discussion at literally the lowest level when defining needs, and I cannot speak for the surgeon general, for the CMP, or the CDS, but by definition, everywhere in the country we would not be able to look after our members without the civilian partnership.

So it certainly is, in principle, something worth exploring.

[Terry Dowdall, Conservative, Simcoe—Grey, ON]

Do you think there is a gap? There's a perception of a gap. Do you actually think there's a gap in access to services during those transition periods?